title: Comprehensive and integrated district health systems strengthening: the Rwanda Population Health Implementation and Training (PHIT) Partnership.
abstract: BACKGROUND
  Nationally, health in Rwanda has been improving since 2000, with considerable improvement since 2005. Despite improvements, rural areas continue to lag behind urban sectors with regard to key health outcomes. Partners In Health (PIH) has been supporting the Rwanda Ministry of Health (MOH) in two rural districts in Rwanda since 2005. Since 2009, the MOH and PIH have spearheaded a health systems strengthening (HSS) intervention in these districts as part of the Rwanda Population Health Implementation and Training (PHIT) Partnership. The partnership is guided by the belief that HSS interventions should be comprehensive, integrated, responsive to local conditions, and address health care access, cost, and quality. The PHIT Partnership represents a collaboration between the MOH and PIH, with support from the National University of Rwanda School of Public Health, the National Institute of Statistics, Harvard Medical School, and Brigham and Women's Hospital.
  
  
  METHODS
  The PHIT Partnership's health systems support aligns with the World Health Organization's six health systems building blocks. HSS activities focus across all levels of the health system - community, health center, hospital, and district leadership - to improve health care access, quality, delivery, and health outcomes. Interventions are concentrated on three main areas: targeted support for health facilities, quality improvement initiatives, and a strengthened network of community health workers.
  
  
  METHODS
  The impact of activities will be assessed using population-level outcomes data collected through oversampling of the demographic and health survey (DHS) in the intervention districts. The overall impact evaluation is complemented by an analysis of trends in facility health care utilization. A comprehensive costing project captures the total expenditures and financial inputs of the health care system to determine the cost of systems improvement. Targeted evaluations and operational research pieces focus on specific programmatic components, supported by partnership-supported work to build in-country research capacity.
  
  
  CONCLUSIONS
  Building on early successes, the work of the Rwanda PHIT Partnership approach to HSS has already seen noticeable increases in facility capacity and quality of care. The rigorous planned evaluation of the Partnership's HSS activities will contribute to global knowledge about intervention methodology, cost, and population health impact.
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda. pdrobac@pih.org
authors.forename: Peter C
authors.initials: PC
authors.lastname: Drobac
authors.forename: Paulin
authors.initials: P
authors.lastname: Basinga
authors.forename: Jeanine
authors.initials: J
authors.lastname: Condo
authors.forename: Paul E
authors.initials: PE
authors.lastname: Farmer
authors.forename: Karen E
authors.initials: KE
authors.lastname: Finnegan
authors.forename: Jessie K
authors.initials: JK
authors.lastname: Hamon
authors.forename: Cheryl
authors.initials: C
authors.lastname: Amoroso
authors.forename: Lisa R
authors.initials: LR
authors.lastname: Hirschhorn
authors.forename: Jean Baptise
authors.initials: JB
authors.lastname: Kakoma
authors.forename: Chunling
authors.initials: C
authors.lastname: Lu
authors.forename: Yusuf
authors.initials: Y
authors.lastname: Murangwa
authors.forename: Megan
authors.initials: M
authors.lastname: Murray
authors.forename: Fidele
authors.initials: F
authors.lastname: Ngabo
authors.forename: Michael
authors.initials: M
authors.lastname: Rich
authors.forename: Dana
authors.initials: D
authors.lastname: Thomson
authors.forename: Agnes
authors.initials: A
authors.lastname: Binagwaho
mesh_terms: D000293:Adolescent; D000328:Adult; D019058:Community Networks; D019033:Delivery of Health Care, Integrated / Q000191:economics / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D016730:Program Development; D058996:Quality Improvement / Q000458:organization & administration*; D019035:Rural Health Services; D012432:Rwanda; D055815:Young Adult